Purpose

This Program Assistance Letter (PAL) amends Program Information Notice 2007-17 (PIN 2007-17).  This PAL confirms that the processes and requirements for applying for initial accreditation remain consistent with the guidance described in PIN 2007-17 and offers guidance on new and expanded opportunities for training and survey services for organizations funded under the Health Center Program (section 330 of the Public Health Service Act).  This PAL contains instructions for health centers to apply for technical assistance, training, mock surveys, and survey services under the current contract with The Joint Commission (TJC).

Introduction

The Accreditation Initiative services for eligible Health Center Program grantees were initially established by the Health Resources and Services Administration (HRSA) through a contract with TJC, formerly known as the Joint Commission on Accreditation of Healthcare Organizations.  The current three-year contract with TJC provides for survey services for ambulatory care, behavioral health care, limited laboratory services, and technical assistance and training for health centers.  Eligible entities under the Accreditation Initiative ("health centers") are organizations receiving funding under the Health Center Program (Migrant Health Centers, Community Health Centers, Health Care for the Homeless Centers, and Public Housing Primary Care Centers). 

To help encourage health centers to become accredited, HRSA has increased both survey services, and technical assistance and training offered to health centers under the Accreditation Initiative for the current contract year (April 1, 2008 – March 31, 2009). 

INFORMATION/APPLICATION PROCESS FOR INITIAL SURVEYS

Application for Initial Services

The Accreditation Initiative is continuing to accept applications and it is still possible for health centers that are not currently accredited to apply for initial accreditation. Organizations interested in HRSA support for initial accreditation under the Accreditation Initiative during the contract year should forward an application/letter of interest (LOI) directly to the Accreditation Initiative Program accreditationinitiative@hrsa.gov. For further instructions on how to apply for initial accreditation please review PIN 2007-17 located on the HRSA website at: http://bphc.hrsa.gov/policy/pin0717.htm.

Mock Surveys

Through TJC’s affiliate, Joint Commission Resources (JCR), one day mock surveys will be provided to HRSA grantees to assist in their preparation for their initial Accreditation Survey.  Requests for a mock survey should be submitted by letter/email to JCR at ConsultingServices@jcrinc.com, indicating that the request is part of the HRSA Accreditation Initiative, and including a short description of the reason(s) for requesting this assistance and the month they would like to have the mock survey. 

Materials from The Joint Commission to Support Initial Survey

After a health center is approved by HRSA for their initial survey, TJC will send further information on the accreditation process to the grantee, including:

1. The most current Comprehensive Accreditation Manual for Ambulatory Care;
2. Access to the health center’s dedicated extranet site on TJC’s web site;
3. Details regarding the Application for Accreditation process; and
4. Instructions on how to achieve compliance with standards and prepare for your survey.

ADDITIONAL SERVICES FOR ACCREDITED HEALTH CENTERS

A.  Health Center Re-Accreditation Surveys  

Organizations eligible for resurvey during the contract year under the HRSA Accreditation Initiative will be contacted directly by TJC to coordinate their re-accreditation survey. TJC will continue its policy of conducting unannounced resurveys in an attempt to ensure that health centers are prepared for the next patient not the next survey and will maximize the number of resurveys conducted during this contract period to prevent lapses in accreditation status.

B.  Laboratory Services Fees And Survey Cost

HRSA will pay TJC’s annual fees for accredited laboratory services during the current contract year. In addition, HRSA will pay the on-site survey costs for TJC laboratory surveys conducted from September 2008 through March 2009, to include the off cycle surveys.

MATERIALS AND PUBLICATIONS

TJC will provide each HRSA Accreditation Initiative health center participant with the following two publications in order to inform grantees about the new tracer methodology survey technique and to help in performance measurement: “Applied Tracer Methodology: Tips and Strategies for Continuous Systems Improvement,” and “Tools for Performance Measurement in Healthcare: A Quick Reference Guide.”

TRAINING AND EDUCATIONAL RESOURCES

TJC will provide HRSA grantees access to participate in the following technical assistance and educational training opportunities related to survey preparation and compliance with standards.

Sponsored educational and training sessions

TJC will conduct educational and training sessions lasting three hours or less, to be held in conjunction with the logistical sponsorship of another organization (e.g., health center, primary care association, regional or national organization representing health centers, clinical network) similar to the process used for the annual Uniform Data System trainings.  These training sessions will be conducted by a TJC representative and may be tailored to the requester’s specific area of interest. The TJC honorarium fee is paid by HRSA and the sponsoring organization is responsible for the costs related to the travel and per diem of the TJC representative.  To request a training session, an organization should contact the Joint Commission Project Director at (630) 792-5011 for approval for this training.

Breakfast Briefing Audio Webinars on the Ambulatory Care Standards

The TJC affiliate, JCR, will provide HRSA grantees with a 9 part series of training teleconferences that focus on ambulatory care accreditation standards, key changes and revisions to the contract, the new National Patient Safety Goals, as well as strategies for maintaining continuous compliance.  This audio/web-based “Breakfast Briefing Series” will consist of a one-hour presentation with accompanying slides.  Grantees will also be able to download each session for a “listen on demand” format for any missed sessions.  Requests to participate in and download playback information for the Breakfast Briefing Series should be made by contacting the Joint Commission Project Director at (630) 792-5011.

Customized Group Teleconferences

The Joint Commission Project Director is available to conduct up to 4 teleconferences with an individual health center or groups of health centers leadership, clinical staff, or board members regarding the benefits, obstacles, resources, and preparation steps relating to accreditation.  Requests to schedule a customized group teleconference should be made by contacting the Joint Commission Project Director at (630) 792-5011

Performance Improvement Technical Assistance

CONTACTS

Additional information regarding the application process for TJC can be found at (http://www.jointcommission.org).  Questions and comments pertaining to this PAL should be referred to the Accreditation Initiative Program at accreditationinitiative@hrsa.gov, or (301) 594-0818.